Yes, the title deserves all capital letters. OSCEs are Very Important to our Education. They allow us to test our Clinical Skills and Patient-Centered Method. Plus they give us Clinical Experience while allowing for immediate Feedback.

Yada yada yada.

OSCEs are… special. For those who don’t know, the Objective Structured Clinical Exam is a mix of history taking and physical exams designed to evaluate the blossoming medical student on their skills in both. Well-intentioned, but fundamentally flawed, really. “How so?” you ask with immense curiosity. Well, I’m about to tell you, young grasshopper. Without further ado, here’s 5 ways that OSCEs are nothing like real life.

The patients are actors.

I know it shouldn’t matter. I know I need to act professionally and treat them with the same respect and dignity as a real patient.

But still.

It’s really hard to connect with some of them – a part of your brain is continuously keeping track of the fact that they’re not themselves. Hence, when you ask about their occupation or medications, your mind quickly and conveniently adds quotation marks to their statements. “Occupation.” “Medications.” They seem to have “pre-syncopal episodes.” The patient reports long-standing “hypertension.” It’s rather annoying, but totally automatic. No turning that business off.

2. The scenarios are simplistic.

THIS IS NOT A BAD THING. In fact, it’s necessary so that we can get through a focused history in 7 minutes. However… the environment is so hopelessly synthetic and the “point” of the station so dramatically obvious that it’s hard not to roll your eyes a bit. Chances are, most patients with high blood pressure aren’t coming in *just* because they have erectile dysfunction and would like to discuss how that makes them feel. (FIFE, anyone?) In Real Life, they’d probably have pre-diabetes to worry about, maybe an enlarged prostate, and have gout that’s giving them grief.

3. There’s an ultimate-supreme, omniscient Observer in the room.

This has become less of a big deal than when I first started… but when I walked into my first OSCE station, I was utterly mortified. All I knew was that there was an official-looking person tucked away in a corner, watching my every move, documenting every mistake, and (essentially) appraising me as a future doctor.

Eep.

But really, it’s not so much that there’s someone judging me. I’ve performed and spoken publicly tons of times, and an OSCE is no different. It’s a performance. In fact, just today I had several people remark how relaxed and organized I seemed. Truth: I had a nervous tremor for the majority of the first station and I had to rack my brains at least a few times, trying to remember what came next in the exam/history. Fake it till you make it, right?

Anyway, the thing that’s a bit unrealistic is that there’s not going to be someone checking your work on the wards. At least, not all the time. There’s not going to be somebody with the scenario in their hand, checking to make sure you got all the important parts of the history. There’s nobody to hold your hand and give you instantaneous feedback. It’s all you.

4. We wouldn’t know what findings looked like if they smacked us in the face with a dead trout.

One of my biggest peeves. In the OSCE, we’re graded on being able to perform maneuvers, not report findings. (A “finding” is something unusual, like having a very fast heart rate or jaundice in the sclera of the eyes.) But this really isn’t helpful in proving that we’re Skilled Clinicians.

For example, take auscultating (listening to) the heart. It’s a skill that only comes with tons and tons of practice. You have to have heard a hundred normal hearts before you really know where that one abnormal sound fits. But you can miss a grade VI murmur and still get 100% on the cardio OSCE station. Just because you went through the motions perfectly. Lolwut?

5. After an OSCE, I feel invincible.

There’s no WAY being on the wards is like this all the time. I literally walked out of my OSCE today with a big ole grin on my face. The stations all went well, the standardized patients were all exceptionally nice and the observers gave some great feedback. I walked down the hallway, practically skipping, and thought something to the effect of “DAMN, I’m gonna be a superstar doctor someday.”

Somehow I don’t think that translates to life on the wards. At least not every day. Because guess what? We’re going to be dealing with sick people. And people hate being sick. And they’re gonna tell you so. And they’re gonna tell you whatever else is going wrong, including what you’re doing. Not because they’re awful people, but because they’re miserable and just want to be well.

I realize that eventually we’ll have our “Difficult Patient” OSCE and all we’ll be dealing with is people who have problems communicating effectively and/or are really sick. But in doing so, they’re creating a bit of a false dichotomy, grouping patients into either the “Cooperative” or “Uncooperative” slots. I like to think that it’s more of a spectrum. You’re not going to get along with absolutely every patient you see, and there’s a wide range of how well you “click,” so to speak. For some patients, you’ll feel like you’ve known them forever and that you can do no wrong in their eyes. For others, you’ll dread the days their name appears on your schedule. For still others, you might have mixed feelings about how well they’re controlling their glucose levels and diabetic neuropathy.

Not every day in medicine is a good day. I guess that’s what I’m trying to get at. I’ve never had a “bad” OSCE, which isn’t a very good representation of how life’s going to be for the next 40 years.

IMPORTANT CONCLUSION: OSCEs are fun. And hard. Sometimes. And sometimes useful. But sometimes not.

AND NOW FOR SOMETHING COMPLETELY DIFFERENT…

Thanks to everybody who attended the Winter Concert this past Tuesday – it was a rip-roaring success! For those who have no idea what I’m talking about, look for videos coming (hopefully) next week…

Happy studying!

For the folks in my class, how did your OSCE go today? For the other folks, what improvements would you make on the OSCE format?

This is all so true! OSCEs are in a sense ridiculous and yet a valuable experience. I always find myself looking for little things that remind me the people are actors (like noticing when they thought a little too long about if they are married or where they work or what have you… something not in the scenario… most of them are so good you don’t notice, but the odd one…). The evaluator is definitely the most nerve-wracking person. Especially if they are someone you worked with before. Once, though, at a history only station, I walked in and introduced myself to the evaluator like they were the patient. Awkward.

My favorite OSCE scenario back in the day was when the patient was complaining of a rash. The “rash” consisted of some odd skin colored putty on his forearm with what looked like 2 washers (or maybe Cheerios?) underneath. I thought it was nothing spectacular and started talking to the guy about travel history and sexual history when I think I was supposed to think that the ridiculousness on his arm was smallpox! (This about 6 months after 9/11 when bioterrorism was the big, bad boogie-man). I’m just glad I was in the last class of medical students that did not have to take Step 2 CS. Not to rub it in or anything…

Total geek + family med resident = so much win.

Disclaimer: I am a 1st year resident. Officially I now know some stuff. However, this blog is for your entertainment (including, but not limited to, giggles, snorts of laughter, eye-rolling, fist pumping, and shouting at your computer screen) and is not a good substitute for a visit to your family doctor's office.

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